Dizziness Questionnaire
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Patient Name *
Date of Birth *
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ENT Physician
Primary Care Physician
Describe your symptoms: *
When did your symptoms begin? *
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How long have your symptoms been going on? *
Pflichtfrage
Onset nature: *
Select all that apply DURING your dizzy spells: *
Pflichtfrage
Imbalance when walking? *
Comes in attacks or episodes? *
How often? *
How long do they last? *
When was the last attack or episode? *
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MM
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Are you completely free from dizziness between attacks/episodes? *
Do you have any warning signs prior to an attack/episode? *
If yes, please explain. If not, simply write N/A
Have you had any head injury or trauma within the last 12 months or around the onset of dizziness symptoms?
 *
If yes, please explain. If not, simply write N/A
Dizziness/Imbalance worsens with or triggered by: 
 *
Pflichtfrage
Is there anything else you can do to help alleviate your dizziness? *
If yes, please explain:
Other sensations include:
My current symptoms also include (can occur with or without dizziness episode):
Have you ever worn or currently wear hearing aids? *
Medical History also includes: *
Pflichtfrage
What physicians or specialists have you seen previously FOR YOUR DIZZINESS? 
If you have seen a Physical Therapist, how many visits?

What tests have been done previously FOR YOUR DIZZINESS?

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